At last year’s annual American Psychiatric Association (APA) meeting in Hawaii, some prominent psychiatrists wanted to picket the convocation speech of South Africa’s Archbishop Desmond Tutu because of allegations of his possible anti-Semitism. It was a near-protest—but it fizzled out.
Maybe the “Occupy Wall Street” movement suggests a different kind of protest for this year’s meeting. What about “Occupy Medicine” for us psychiatrists? This may sound somewhat ridiculous, given that psychiatrists still make a good living, but we are surely in the 99% of medicine. In fact, we may be in the lower 1% for reimbursement, and high-tech surgeons are in the upper 1%. Managed care companies, Medicaid, and Medicare steeply discount our fees, which are already low. I’m often struck that plumbers make more per hour.
Some may make the counter argument that psychiatrists are increasingly important in the house of medicine. More and more of us have taken on leadership roles in the AMA.
Of course, psychiatrists can be criticized for not using our medical training sufficiently in our clinical work. How often we even take vital signs varies quite a bit.
Nevertheless, other medical and mental health professionals have also taken over our business to a great extent. Take primary care physicians, who now prescribe well over half of psychiatric medication prescriptions, despite evidence of limited expertise and success. Primary care physicians don’t even do much minor surgery. Nurse practitioners are hot on the trail of primary care physicians, and in many states and settings, they can prescribe independently (with just with a Master’s education). Psychologists keep trying to join this parade, though so far psychiatrists have risen up in successful protest.
Then there is our other area of major treatment expertise—psychotherapy. Right from the get-go of psychoanalysis—even though Freud was a psychiatrist (and earlier, a neurologist)—other mental health disciplines, even lay people, were allowed and encouraged to become psychoanalysts. Since then, psychoanalytic and newer forms of psychotherapy have been adopted by all disciplines, especially psychology and social work. In some states, unlicensed therapists can freely practice. As managed care has escalated and reduced reimbursement, psychiatrists are doing less and less psychotherapy.
Sure, there are some newer medical psychiatric procedures, like transcranial magnetic stimulation and vagus nerve stimulation, where psychiatrists are dominant. But, for how long and for how many patients?
Where we’ve really given up our product is in diagnosis. Though the APA has put out the official diagnostic manuals in the United States for decades, it opened up its use to any clinician who claimed enough expertise and knowledge. The APA makes a lot of money selling these manuals to other clinicians, who far outnumber psychiatrists, but what does this do to our role and status?
This generosity with DSM authority seems to be a paradox. As we have given away—or had taken away—our leadership roles in many institutions, even medical schools, here we are still in charge. As important as what the diagnostic criteria might be, so is who is qualified to use them. Given that many diagnoses have medical rule outs and considerations, psychiatrists in general should be the most qualified.
Psychiatry is a strange kind of business. We’ve given out our products for free, then watched as other businesses—whether they be other types of clinicians or insurance companies—take over what we do.
Care to try to reclaim more of that 99%? Let us try to reclaim some of our lost leadership. Let us reclaim the upcoming DSM-5 as ours. Let us reclaim the subtle complexity of psychopharmacology and draw the line that other prescribers should have just one strike until we are called in for relief. Let us make clear that combined medication and psychotherapy in one clinician, that is, the psychiatrist, is usually cheaper and more effective for many patients.
However, there is a big obstacle. Psychiatrists, with our Freudian history of being introverted listeners, tend to caring and compassion, but passively. Maybe even at times and places, passive-aggressively. So, we’ve tended to go our own way, adapted to changes in our field, and complained to one another.
Thankfully, the anti-psychiatry movement has died down. In an unexpected way, there’s more of a pro-psychiatry movement becoming embedded in our systems. These are our patient consumers and peer specialists. Could they be recruited as our advance force for Occupy Medicine? Who knows better? Most naturally our patients and their families know what the illnesses have caused them to lose and what they need to recover.
Fittingly, this year’s APA meeting will be in Philadelphia, Pennsylvania, where our country’s Declaration of Independence from Britain was developed and signed. Maybe we psychiatrists should resolve in this New Year to develop a new declaration of our land.